Plantar fasciitis is probably the most common cause of pain under the heel. Symptoms come on gradually and are often worse first thing in the morning, but ease a little when the foot is warmed up. Here we explain everything you need to know about curing Plantar Fasciitis including treatment, taping, exercises, sports massage and more.
Symptoms
Symptoms of plantar fasciitis consist of a gradual onset of pain under the heel which may radiate forwards into the foot (foot arch pain). There may be tenderness under the sole of the foot and on the inside of the heel when pressing in. The pain can range from being slightly uncomfortable to very painful depending on how badly it is damaged.
Pain is usually worse first thing in the morning because the foot has been in a relaxed position all night and the plantar fascia temporarily shortens. After walking around this usually eases as the tissues warm up and gradually stretch out. When the condition is present, similar periods of moving around following inactivity such as sitting for long periods can also trigger the pain.
Read more on assessment and diagnosis.
Causes & anatomy
The Plantar Fascia or plantar aponeurosis as it is also known as a broad, thick band of tissue that runs from under the heel to the front of the foot. It comprises three segments which originate from the base of the heel bone (calcaneus bone) and inserts into the forefoot.
The middle segment forms the longitudinal arch of the foot providing support to the foot when standing and shock absorption when running. It is an overuse injury caused by repetitive over-stretching of the fascia which can become inflamed and painful at its attachment to the heel bone or calcaneus.
The condition is traditionally thought to be inflammation, however, this is now believed to be incorrect due to the absence of actual inflammatory cells within the fascia and degeneration is thought to be a more likely cause. It is more common in sports which involve running, dancing or jumping.
Although overuse is usually thought to be the cause of plantar fasciitis there are a number of factors which can increase the likelihood of developing the condition:
Overpronation is where the foot rolls in or flattens. As the foot flattens it stretches the plantar fascia more than normal which increases the strain on the tissues, particularly the insertion into the underneath of the heel- High arched foot (pes cavus) causes an increased strain on the attachment of the plantar fascia to the heel. This kind of foot is often rigid and unable to absorb shock whilst running or adapt to the ground.
- Wearing inappropriate footwear such as very flat and unsupporting shoes can increase the likelihood of developing plantar fasciitis.
- Overweight individuals or those who do a lot of heaving lifting at work will place increased load on the foot increasing the chances of developing heel pain.
- Tight muscles are thought to be a risk factor. Tight hamstring and gluteal muscles, as well as hip muscle imbalances, are thought to predispose people to plantar fasciitis as they affect foot biomechanics. In particular, tight calf muscles and a tight plantar fascia are thought to be significant.
Plantar fasciitis treatment
Treatment consists of reducing pain and inflammation, stretching the plantar fascia and lower leg muscles, correcting any causes followed by a gradual return to fitness. Heel pain can be very stubborn to treat and often a combination of approaches is best in treating this injury.
Self-help treatment
Reducing pain and inflammation is the first priority of plantar fasciitis treatment. Applying the PRICE principles of protection, rest, ice, compression and elevation is important. Apply ice or a cold therapy wrap to help reduce pain and inflammation. Cold therapy can be applied for 10 minutes every hour if the injury is particularly painful for the first 24 to 48 hours. This can be reduced to 3 times a day as symptoms ease. Ice should not be applied directly to the skin but through a wet tea towel to avoid skin burns. Commercial gel hot and cold packs and wraps are a more convenient method of application.
Taping the foot is an excellent way of instantly relieving the symptoms and pain under the heel. There are various methods of applying tape for this injury. It works by unloading some of the strain on the plantar fascia allowing the tissues to heal. It may need to be applied regularly until symptoms resolve but many people notice an immediate improvement.
Protect the foot by wearing comfortable shoes or trainers. Hard or flat soled shoes are likely to make symptoms worse. Wearing can provide protection of the painful area under the heal and a simple plantar fasciitis taping technique is ideal for taking the pressure off the plantar fascia and allow the foot to rest and aid healing.
Plantar fasciitis stretches are important as soon as pain allows. A night splint is a very effective way of stretching the plantar fascia under the heel. It is worn overnight and helps prevent the arch of the foot tightening up.
What can a professional do?
A professional therapist can make an accurate diagnosis and advise on a full treatment and rehabilitation plan. A doctor may prescribe anti-inflammatory medication such as ibuprofen in the early stages to reduce pain and inflammation and a therapist may use electrotherapy such as ultrasound or laser treatment to relieve symptoms.
In the later stages, deep tissue massage techniques can be applied to help stretch and relax the fascia.
Gait analysis may be done to identify biomechanical foot problems and orthotic inserts prescribed.
For more stubborn injuries a corticosteroid injection may be given and if symptoms do not resolve then surgery is an option but this is rare.
Read more on treatment and rehabilitation.
Do I need surgery?
Surgery is used in around 5% of people whose symptoms do not improve, even after continuous treatment. However, the success rate is still only estimated at around 70-80%. In most cases now a procedure called a plantar fascia release is performed which releases (cuts) between 30 and 50% of the fascia's fibres. This helps to reduce the pull and stress on the bony attachment, as well as the fascia itself. Complications can include nerve damage, fallen arches, infection and ongoing symptoms. Recovery after surgery if successful is around 9 to 12 weeks before the patient may return to work. Read more on surgery.
Plantar fasciitis exercises
Exercises to stretch the plantar fascia and the calf muscles are important. Resting alone may reduce pain and inflammation but if part of the cause is tension in fascia then the injury is likely to recur.
Calf muscle stretches
Calf stretches with the leg straight (to target the larger gastrocnemius muscle) and with the knee bent (targeting the lower soleus muscles) can be done 3 to 5 times a day. Hold stretches for up to 30 seconds at a time and they should be done pain-free.
Plantar fascia stretch
The plantar fascia stretch is done by pulling the foot and toes upwards aiming to feel a stretch in the arch of the foot. Rolling the foot over a ball can also help stretch underneath the foot.
Strengthening exercises are not normally needed, however scrunching a towel up with the toes can get the small muscles of the foot working.
Read more on exercises.
